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Satisfaction Survey
Welcome! Please take a few moments to complete this brief survey.
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1
Name of person completing this survey.
*
This field is required.
First Name
Last Name
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2
What is your relationship to our office?
Client
Healthcare Office
Parent/Guardian/Family Member
Community Service Organization
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3
What services were received from our office?
Counseling
Primary Care/ Medical Services
Medication Management
Community Support
Telehealth Medicine
Psychological Testing
Substance Abuse Treatment/Evaluation
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4
Name of provider(s)
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5
Name of treating provider.
Select all that apply.
Debra Erickson
Jordan Hofmann
CeCe Bacon
Cindy Betka
Evelynn Freeman
Sara Gasper
Dave Hoyt
Chantal Kohl
Cheryl Lockett
Raquel Moreno-Izaguirre
Suzanne Riley
Laurie Robinson
Deborah Thimsen-Villa
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6
Overall satisfaction
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Provider
Waiting Time
Front Desk Staff
Success of Treatment
Scheduling/Communication
Comfort of Environment
Accommodations of Needs
Billing Procedures
Provider
Waiting Time
Front Desk Staff
Success of Treatment
Scheduling/Communication
Comfort of Environment
Accommodations of Needs
Billing Procedures
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
Very satisfied
Satisfied
Neutral
Unsatisfied
Very unsatisfied
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7
How can we improve our service?
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8
Would you like us to contact you regarding your satisfaction with our office?
YES
NO
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9
If you would like us to contact you regarding your satisfaction with our office, please provide your name phone number.
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10
Date of survey
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Date
Month
Day
Year
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